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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 1082959-CCC (Child Care Center) Investigator(s): Beth Virden beth.virden@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) left an alleged victim (AV) in the bathroom unsupervised for ten minutes. Date of Incident(s): December 5, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.
Summary of Findings: Pertinent information was obtained during a site visit conducted on December 28, 2023; from documentation at the facility; and through interviews conducted with the AV’s family member (FM), facility staff persons (the SP and P1), and a supervisory staff person (P2). Some information was also provided by a facility administrative staff person (P3). [Note: The FM said that the AV did not say anything about the incident and did not appear impacted in any way. The FM did not believe the AV would remember what happened. The AV was not interviewed.] At the time of the incident, the AV was three years old and enrolled in the facility’s preschool classroom. The facility occupied space within a community church. The classrooms were clustered together in a church hallway. The AV’s preschool classroom had a door to the hallway and also had another door, which connected to another preschool classroom. There was a student single-stall bathroom in the second classroom, which was commonly used by students in either room. The bathroom had a door, which could be closed for privacy. The bathroom, itself, was directly next to the door connecting the two classrooms meaning the bathroom was immediately inside the room or within five feet of the classroom connection point. The facility’s policies and procedures provided the following information: · Counting of children will be done on the quarter hour throughout the day (on the hour, 15 after, half past and quarter to). Staff will work as a team to designate a counter for each time frame. · When staff leaves the room with child(ren) that staff needs to notify the other teacher(s) of the number of children they are taking and how many are left in the room. · Staff persons are prohibited from leaving a child/children alone or unsupervised either indoors or outdoors. Children must have direct staff supervision at all times. The SP provided the following information: · At the time of the incident, parents were arriving to pick up their children; and as the children were leaving, classrooms were combining into smaller spaces. Another classroom combined with the AV’s class in the AV’s classroom (the classroom without the bathroom). · Around 3 p.m., the AV approached the SP and asked to use the bathroom. · The SP guided the AV through the door connecting the two classrooms and to the bathroom. The AV entered the bathroom and asked to close the door for privacy. According to the SP, staff had been recently told that students could have the door closed if they wanted and that when this occurred, staff should check on the student in the bathroom at least every five minutes. · The AV entered the bathroom and closed the door behind him/her. · The SP remained outside the bathroom door or nearby within the same classroom responding to emails and completing end of day business. The SP received a message from a supervisory staff person about an unrelated enrollment issue and was writing out that week’s snack list. “As that was going on, I walked out (of the classroom) at some point into the other classroom … It slipped my mind (that the AV was still in the bathroom) … I walked past the bathroom without thinking.” The door connecting the two classrooms was closed. There was a window in the door allowing visibility into either room. [Note: When the SP left the classroom, the AV was the sole person in that classroom.] · The SP said that s/he walked out of the classroom and took a phone call and that based on this call time, s/he believed it was “within ten minutes” after leaving the room, the AV was seen on the other side of the door waving through the window to get staff attention. However, the SP was not positive on “the timings.” · The AV was then let back into the room and was “not at all” injured. The AV was “smiling” and immediately asked the SP to “play together.” · According to the SP, the other classroom, where the AV had been unsupervised after finishing in the bathroom, did not have any accessible hazards. This classroom was occupied by children, the same age as the AV, almost every day and so there was nothing in the room that was not already accessible to the AV in his/her regular room. · The SP described the AV as “extremely smart … top in the class for [his/her] age … very intelligent.” P1 and P2 provided the following information: · P1 and P2 each said that on the day of the incident, the SP was working with P1 and another staff person (P4). There were 11 children in the room, including the AV. P1 heard the AV ask to use the bathroom and was aware the SP took the AV into the other classroom for that purpose. [Note: P4 was no longer working at the facility and was not interviewed for this investigation.] · An unknown time later, P1 saw the SP reenter the classroom and close the connecting door behind him/her. P1 did not look for the AV and assumed s/he had returned with the SP. P1 was playing with other children. “Sometime later,” or “between five and ten minutes … not more than 15 minutes,” staff saw the AV standing on the other side of the door waving through the window. The AV was not injured or crying. · P1 had been trained to count the children at transitions and “quite often” at various other points. At the time of the incident, staff did not notice the AV was immediately missing because it had not come time to count prior to the AV returning on his/her own. · P1 and P2 did not have prior concerns with the SP’s conduct. P2 said that the SP was “an awesome teacher.” · P1 described the AV as “one of our best kids.” P3 said that the facility had cameras in the classrooms; however, the camera system at the time of the incident was not saving appropriately and was not viewable. When P3 initially asked the SP about what happened, the SP said that the AV was in the other classroom for “15 minutes.” However, “[The SP] did not differentiate if [s/he] was in the room for part of that or not.” In other words, the SP did not clarify whether the 15 minutes included the time when s/he remained in the same classroom as the bathroom before leaving to the other classroom. P3 did not have a way to determine this without the camera footage. The FM was informed of the incident by the facility. The FM did not have prior concerns with the facility’s overall care and supervision. The AV was not impacted by the incident. Facility documentation stated that the SP, P1, and P2 received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Minors Act.
Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states that a child must have supervision at all times and that supervision is defined as occurring when a program staff person is within sight and hearing of a child at all times so that the program staff person can intervene to protect the health and safety of the child. Minnesota Statutes, section 245A.02, subdivision 18, paragraph (c), states that when a single preschooler uses an individual, private restroom within the classroom with the door closed, supervision occurs when a program staff person has knowledge of the child’s activity and location, and can hear the child, and checks on the child at least every five minutes. Conclusion: A. Maltreatment: Consistent information was provided that on December 5, 2023, the SP helped the AV to the bathroom that was a single stall located in an unoccupied classroom connected to the AV’s and the SP’s classroom. The bathroom had its own door, and the two classrooms were separated by a door with a window. The AV asked to close the bathroom door. The SP approved this and then waited near the bathroom for the AV to finish, but eventually walked back into the other connected classroom and “forgot” about the AV in the bathroom. The door between the two classrooms was closed. Although the SP initially remained in the classroom where the bathroom was located, the SP then left the room and failed to maintain knowledge of the AV's activity and location and failed to check on the AV at least every five minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, paragraph (c). It was not known exactly how long the AV was alone in the other classroom after the SP left to the adjoining room. P3 said that the SP initially told him/her that the AV was in the other classroom for 15 minutes, but at that time the SP did not differentiate the time s/he was in the room that adjoined the bathroom or back in the classroom. The SP said s/he believed s/he was back in the classroom “less than ten minutes” when they saw the AV and P1 believed it was “between five and ten minutes … not more than 15 minutes.” Leaving the AV unsupervised in a bathroom in an unoccupied classroom was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Given that the AV was unsupervised for likely between 10 and 15 minutes and that staff did not know the AV was missing so they were unable to intervene to protect the AV if necessary or in the event of an emergency, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions that seriously endangered his/her physical or mental health. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so; and/or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the care and supervision of the AV when s/he brought the AV to the bathroom in the unoccupied classroom and left him/her and returning to the classroom. The SP received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Minors Act. The SP was responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated maltreatment for which the SP was responsible in this report was not serious or recurring. However, information obtained by the Department of Human Services, in combination with this report, would result in the SP being disqualified for recurring maltreatment. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility provided additional training to staff persons, instructed staff to keep the door open between the two classrooms, and planned to change the bathroom door, itself, for greater visibility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. On February 23, 2024, the facility was issued a Correction Order for the violations outlined in this report. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right
to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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